Lab Assignment: Assessing The Abdomen HW 2

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)

Objective:

VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None

Assessment:

Left lower quadrant pain
Gastroenteritis

ORDER CUSTOM, PLAGIARISM-FREE PAPER

C H A P T E R 3

Abdominal pain Abdominal pain is a subjective feeling of discomfort in the abdomen that can be caused by a variety of problems. The goal of initial clinical assessment is to distinguish acute lifethreatening conditions from chronic/recurrent or acute mild, selflimiting conditions. Assessment is complicated by the dynamic rather than static nature of acute abdominal pain, which can produce a changing clinical picture, often over a short period of time. In addition, both children and older adults tend to deviate from the usual and anticipated clinical pattern of abdominal pain. The following three processes can produce abdominal pain: (1) tension in the gastrointestinal (GI) tract wall from muscle contraction or distention, (2) ischemia, and (3) inflammation of the peritoneum. Pain can also be referred from within or outside the abdomen.

Colic is a type of tension pain. It is associated with forceful peristaltic contractions and is the most characteristic type of pain arising from the viscera. Colicky pain can be produced by an irritant substance, from infection with a virus or bacteria, or by the body’s attempt to force its luminal contents through an obstruction. Another type of tension pain is caused by acute stretching of the capsule of an organ, such as the liver, spleen, or kidney. The patient with this visceral pain is restless, moves about, and has difficulty getting comfortable.

Ischemia produces an intense, continuous pain. The most common cause of intestinal ischemic pain is strangulation of the bowel from obstruction.

Inflammation of the peritoneum usually begins at the serosa covering the affected and inflamed organ, causing visceral peritonitis. The pain is a poorly localized aching. As the inflammatory process spreads to the adjacent parietal peritoneum, it produces localized parietal peritonitis. The pain of parietal peritonitis is more severe and is perceived in the area of the abdomen corresponding to the inflammation. A patient with parietal pain usually lies still and does not want to move.